An MSF doctor checks the pulse of a girl wounded by shelling moments before in Monrovia, Liberia. The girl was pronounced dead. A fresh round of shelling terrorized Monrovia early in the morning (July 25, 2003), as government forces and rebel troops battled for control of the Liberian capital. Photo © Chris Hondros/Getty Images |
When the families in Maimu camp in Liberia hastily packed
their belongings in August this year, it was their fourth time
fleeing the devastating civil war that has consumed Liberia
for more than a decade, with particular intensity the last three
years. These families were not only escaping a combat zone,
they were fleeing from violence directed specifically at them.
They were trying to avoid being looted again, being raped again
– or being killed.
Further south in the camps in Salala, the displaced families
were also frightened. They were trying to decide what would be
their "best" option: the risk of fleeing or the risk of staying. A
cholera outbreak and increasing malnutrition made the situation
even more desperate. They had been without food assistance for
months.
Once more this year, we witnessed how civilians became
deliberate targets of war in Liberia, and how control over
the civilian population was one of the main objectives of
combatants.
We have seen the same in Democratic Republic of the Congo
(DRC), where in May in the city of Bunia (capital of the Ituri
region in the northeast), civilians were deliberately raped and
massacred. We have seen it in Afghanistan, Sudan, Colombia,
Chechnya...
In many places where we are working, war is not just fighting
with guns between rivals for power. It is a deliberate onslaught
on civilians. It is rape of women and girls; it is all-out assault
on the physical and emotional integrity of thousands and
thousands of men, women and children.
Although it is not war or direct violence, sheer inaction in
the face of disease emergencies – HIV/AIDS, malaria, sleeping
sickness, to name only a few – is also causing millions of very
violent deaths of each year.
The failure to respond immediately – or to respond at all
– to crises borne of conflict and disease has led over time to a
perception that they are normal. The longer the response takes,
the more people are deceived by this notion of "normalcy,"
and the more inertia prevails. As a result, we are tolerating the
intolerable. Concerted action to protect civilians and treat their
diseases has in so many cases been sorely lacking; it is as if
governments and international actors are accepting as normal
what is a terrifying, deadly, daily reality for so many people.
Humanitarian action is crucial to alleviate the suffering of
those affected, and to point to those responsible for these
crimes. Humanitarian action must constantly fly in the face of
accepting the status quo. It must struggle against "normal"
becoming either a criminal excuse used by governments to
avoid real responsibility or a way to make millions of broken
lives palatable to donor countries and rich-country publics who
would like to think they are "doing everything they can," even
as people halfway around the world die invisible, anonymous
deaths that we would never consider normal in our own
communities.
A camp for displaced people in DRC. Photo ©Copyright Eva Van Beek/MSF | In DRC, 30km away from Bunia, across Lake Albert, or 100km
down to the southeast in Beni or north in Mambasa, there are
people who have survived unspeakable events this year and
who are telling their stories, sometimes. But move beyond this,
thousands of kilometres to the north in Europe, or across a
continent and an ocean in the United States, or far to the east in
Japan, the idea of what is happening in DRC has not even begun
to take form. This lack of knowledge and interest was clear in
Bunia itself, where since May MSF has been running a small
hospital right next to a camp for displaced people. Between the
end of May and the end of July, 20% of the patients admitted to
our clinic in Bunia suffered from war wounds. One-third of the
war-wounded were women. One-fourth of the war wounds were
on children under five. Rape and sexual assault in the next-door
camp were frequent reasons for visits to the MSF clinic. The
same grim statistics remain as this report goes to press.
Again in the Great Lakes region there has been a clear
absence of political will on the part of the government and
international agencies, and on the part of the warring factions
themselves, to protect and assist people in danger. This has
spanned years of conflict and millions of deaths. Perhaps
this hesitation is because the international community of
states persists in seeing fighting in DRC as a "tribal" conflict.
However, we feel that this is just another way of avoiding the
responsibility to address it: the conflict has been perpetuated
by the surrounding countries and needs to be addressed
internationally and politically. While some response was offered
to the fighting in eastern DRC in the face of the failure of UN
peacekeeping battalion, with the deployment of a European
force led by France and with an extended UN mandate to
protect civilians, the action was essentially inadequate (the
European force was on the ground only a few months with
limited territorial reach). Many people, especially those in
the countryside outside of Bunia, were left with no protection
or assistance, while in the city of Bunia, security during the
day turned to ongoing violence at night. It seems that the
deployment of these forces was based more on the needs of the
politicians than on those of the people needing protection.
Also insufficient was the response to the intense fighting in
Liberia in spring 2003 that left 75% of the country inaccessible
to humanitarian aid and hundreds of thousands of displaced people
crowding in and around Monrovia even as mortars
and bullets were flying. This was simply a continuation of the
international neglect of Liberia that has been the norm for the
last decade or so. MSF teams worked during the height of the
hostilities in Monrovia, providing care to civilians caught in the
fighting.
Where we have seen an expressed interest in the well-being
of civilians it has often been used to promote other goals,
such as peace-building, nation-building and reconstruction.
Yet these goals, however positive and worthy they may be
in and of themselves, should be kept distinct from provision
of humanitarian assistance. Unfortunately, we see exactly
the opposite happening: politicians are using humanitarian
language as a "rationale" or "cover" for war (Iraq); international
agencies are incorporating humanitarian work into broader
political goals such as peace-building and reconstruction
(Angola, Afghanistan, Iraq). Distinctions between humanitarian
and political goals are fading. In Liberia, UN peacekeepers
continue to work closely with the UN's humanitarian agencies.
An MSF national staff vaccinates a child in Zhare Dasht Camp, Afghanistan. Photo ©Copyright Sebastian Bolesch | In Afghanistan, coalition forces are adopting a "humanitarian"
agenda as a way to achieve military goals and extend the
Afghan government's reach. However, we believe that the very
different roles and responsibilities of peace-enforcers and
those charged with assisting civilians in an impartial fashion
cannot be mixed. Confusion leads to increased insecurity for
aid workers and decreased ability to provide independent aid to
people who need it.
The humanitarian idea that must prevail is one of assistance given according to needs alone.
It is time to destroy the idea that
humanitarian work should be used to build peace – or pacify a
country – or establish democracy – or anything else, other than
assist people who are in need regardless of their nationality,
origin, skin color, political affiliation or religious belief. These
other goals can be legitimate political goals, but they are based
on political analysis and political commitment. Humanitarian
action, on the other hand, is based only on an analysis of needs.
It is easy to confuse relief aid with humanitarian aid. Relief
aid can be very valuable assistance, given to people in different
contexts. However, when it is not given solely on the basis of needs
and the principles of independence, neutrality and impartiality, it is
not humanitarian aid. There has been much confusion about these
two kinds of assistance during the recent war in Iraq.
In the run-up to the war in Iraq, the humanitarian idea was
used by the belligerents as a justification for going to war and by
opponents of the war as a justification for peace and pacifism.
After the main hostilities ceased, we concluded that at that
time there was no humanitarian crisis: no mass displacement
of people, no epidemics, no famine. What we did see was
an abrogation of responsibility on the part of the occupying
power, the United States. The coalition did not plan any kind of
emergency intervention for the post-war period; in terms of the
health care sector, hospitals were looted, their management
disintegrated, and the result was that many people who needed
care could not get it. At the same time, humanitarian actors
had great difficulty carving out a space for truly independent
assistance in the country.
The bad consequences of this are clear. Security is a constant
concern and has deteriorated enormously in Iraq, for Iraqis
certainly, and for those trying to assist them. Security is
compromised not only by local actors but by outside forces,
as local and global interests vie for a stake in the future
there. The bombings of UN headquarters there in August, and
International Committee of the Red Cross (ICRC) headquarters
in October, were heinous assaults on innocent civilians and
show how continuing violence is severely limiting the ability of
international agencies and humanitarian organizations to assist
the Iraqi people. Statements on the part of officials in the US
government (that if NGOs pull out of Iraq the "terrorists win"; or
in Afghanistan that NGOs are "force multipliers") only contribute
to the vulnerability of organizations to attacks by associating
them with the political agenda. Our own team in Iraq withdrew
shortly after the ICRC bombing to evaluate the continuation of
our work.
Tent camp used by displaced Chechens in Ingushetia. Photo ©Copyright MSF | Far away from Iraq, in the North Caucasus, conditions for
civilians are very difficult and humanitarian assistance is not
easy to provide. Chechens living in Chechnya and displaced
to neighboring Russian republics of Dagestan and Ingushetia
live in an environment of terror and coercion. In Chechnya,
conflict marks the daily lives of ordinary civilians; at the same
time, independent witnesses are forced out because all actors,
including the authorities, have created an environment of
hostility, harassment, kidnapping and killing, where hundreds
of people disappear, without a trace. The principal victims are
Chechen; yet more and more, independent humanitarian aid
workers cannot escape the terror and violence.
In August 2002, Arjan Erkel, MSF's Head of Mission in the
North Caucasus, was kidnapped in Dagestan, where MSF was
assisting displaced Chechens. Well over one year later, Arjan is
still missing. MSF has worked tirelessly to secure his freedom.
We have also repeatedly called on the Russian authorities to
press their investigation into his kidnapping, which so far has
been a complete failure. We believe they could be doing much
more to find and free Arjan, and that it is their responsibility to
do so immediately. In August 2003, the United Nations Security
Council passed a resolution on the need to protect humanitarian
workers. How can the Russian government vote for this
resolution when it is not working sufficiently for Arjan's release?
Is there a double-standard here for Security Council members
and others?
Inaction by governments and international actors who could
be putting pressure on Russia is slowly crushing Chechens in
the region. Shouldn't we question the rationale of the Russian
government which states that there is no reason for Chechens
to be outside Chechnya because conditions are "normal" there?
The fact that Arjan Erkel is still missing is really a symbol of
the Russian government's success at glossing over what is
really happening in Chechnya and selling it to the international
community of states, which is all too happy to take refuge in its
own inertia and give carte blanche to what is happening on the
ground.
There are many other people who are equally ignored, and
for whom inaction can be equally mortal. These people don't die the "spectacular" deaths of violent combat. These are the
people who die every day because of infectious diseases that
are, in many cases, treatable. Nearly 15 million people each year
succumb to infectious diseases, especially malaria, tuberculosis
(TB) and HIV/AIDS. Curative treatments exist for malaria and TB;
life-prolonging antiretroviral (ARV) therapy exists for HIV/AIDS.
Why aren't these treatments being given to the millions of
people who need them?
Out of the six million people with AIDS in developing countries
who are so sick they need ARVs today in order to survive, only
about 300,000 have access to treatment, and in Africa (where 29
of the world's 42 million infected people live) only 50,000. What
about the others? Has this urgent situation become so big that
we just cannot see it anymore for what it is – an emergency that
deserves an emergency response? Until now a real emergency
response, characterized by rapid reaction backed by sufficient
commitment and money, has been an illusion. There is no
generally accepted focus on treatment; even prevention policies
often do no more than pay lip service to real action.
This lack of urgency in addressing the AIDS crisis has
persisted for so long that it has become the status quo; it has
become normal. The immediate desperation of millions of
people, which should have prompted rapid action, has instead
turned into fatalism and hopelessness. Millions of sick people
are ready to give up because of our inaction. People with malaria
do not fare much better: most of the hundreds of millions of
people who get malaria every year don't have access to effective
treatments, even though they exist. Is deliberately withholding
life-saving medicine from someone who needs it any different
from waging war on that person, or failing to protect him in
times of conflict?
The AIDS crisis is probably one of the largest humanitarian
catastrophes in human history, if measured by the number
of affected people, the quality of their lives and the (unused)
capacity we have to ease their suffering. In the face of this
avoidable suffering, we must offer life-saving treatment to
people most in need. Today we can only bear witness to the
political vacuum surrounding this crisis. Neglecting treatment
for people in need and failing to respond to this emergency
should be considered nothing less than a criminal attitude.
Even MSF is not doing enough. We are providing ARV
treatment to people in developing countries around the world,
with over 10,000 people expected to be under treatment by the
end of 2003. We are showing that treatment is possible in places
where people are poor and where health infrastructure is not
what we would always like it to be. From our experience, when
ARV treatment is provided for free, people are as consistent in
taking their medicine as people in richer corners of the world.
The World Health Organization's goal of providing 3 million
people in developing countries with antiretroviral treatment by
the end of 2005 will need political commitment and money from
donor countries and local governments in order to succeed. But
we need to emphasize that 3 million by 2005 must begin with
three, five, thirty, one hundred or one thousand patients today.
We need to start now. MSF needs to do more to increase the
number of people we are treating, and governments and other organizations need to start providing treatment. Every life is
valuable.
Public-private partnerships encompassing governments,
UN agencies, NGOs, civil society organizations and private
enterprises are increasingly seen as mechanisms to find
solutions to the AIDS epidemic and other global problems.
But in our opinion, politicians have the sole responsibility to
solve these problems. Even though partnerships may be useful,
politicians must not use partnerships to shirk or dilute their own
responsibility, or use partnerships as an excuse for slow action.
For some diseases, there are not even adequate drugs
available as treatment. To change this, MSF has joined public
health and research institutions in Kenya, India, Brazil, France
and Malaysia to become a founding partner in the new Drugs
for Neglected Diseases initiative (DNDi) which is working on
research and drug development for medicines for diseases such
as sleeping sickness, leishmaniasis, malaria and others. DNDi
is also trying to provoke local governments and donor countries
to take up their responsibilities to address these diseases; we
hope that DNDi will put the responsibility – and the response
– on the public sector and governments.
We can provide aid based on needs and speak out about the
criminal response to civilian suffering due to war and disease
emergencies because we are independent. To remain effective
in our mission we must safeguard this independence. We
must continually work to distinguish ourselves from the everexpanding
pool of relief actors and service providers who do
not strictly adhere to humanitarian principles. This is becoming increasingly difficult.
Thanks to the over 2 million private
donors who fund us around the world, over 80% of our income
comes from private sources. This guarantees our financial
independence. For them, but especially for the people we assist
around the world, we are working ceaselessly to safeguard our
independence of action and spirit.
Pretending that humanitarian action is a way to meet political
goals is as erroneous as pretending that humanitarian actors
can provide political solutions. At MSF, this is why we define
ourselves as confronting power, not becoming part of it. Our
aim is to save lives threatened by political interests that leave
little room for considering people in need for what they really
are: human beings. Our role is to cast ourselves against a reality
which ignores this simple idea.
Dr. Morten Rostrup, President, MSF International Council
Rafael Vilasanjuan, MSF Secretary General
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